Sleep disorders in hospitalized adults: Evaluation and management
- Dennis Auckley, MD
Dennis Auckley, MD
- Associate Professor of Medicine
- Case Western Reserve University (MetroHealth Medical Center)
- Section Editors
- Ruth Benca, MD, PhD
Ruth Benca, MD, PhD
- Section Editor — Insomnia
- Professor and Chair, Department of Psychiatry and Human Behavior
- University of California, Irvine
- Nancy Collop, MD
Nancy Collop, MD
- Editor-in-Chief — Sleep Medicine
- Section Editor — Sleep Related Breathing Disorders
- Professor of Medicine and Neurology
- Director, Emory Sleep Center, Emory University
Sleep-related breathing disorders such as obstructive sleep apnea (OSA) and central sleep apnea (CSA) occur with increased frequency in certain inpatient populations and may be associated with worse short-term outcomes. OSA is also common in the general population, is often undiagnosed, and may be first recognized in the inpatient setting. These and other primary sleep disorders are important to recognize, as acute illness and other aspects of hospital admission may aggravate chronic symptoms or bring to light previously unrecognized symptoms.
This review will discuss the evaluation, consequences, and management of sleep disorders in hospitalized adults. An approach to poor sleep in the inpatient setting is reviewed separately. (See "Poor sleep in the hospital: Contributing factors and interventions".)
OBSTRUCTIVE SLEEP APNEA
Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder, and most patients are undiagnosed. OSA may be first recognized in the inpatient setting, when sleep is directly observed and continuous hemodynamic and respiratory monitoring reveal breathing pauses and intermittent hypoxemia.
Prevalence — The estimated prevalence of OSA in the general population is approximately 15 percent in males and 5 percent in females . OSA is significantly under-recognized in the outpatient setting [2,3], and most patients are undiagnosed . (See "Overview of obstructive sleep apnea in adults", section on 'Epidemiology'.)
The prevalence of OSA in the general inpatient population has not been well studied but it is likely to be even higher than in the general population, as the inpatient population is enriched with comorbid conditions associated with OSA, such as obesity, diabetes, hypertension, and cardiovascular diseases [5,6]. Studies using screening questionnaires have found that 40 percent of inpatients ≥50 years old and 87 percent of inpatients with a body mass index (BMI) ≥30 kg/m2 score as high risk for OSA [7,8].
- Peppard PE, Young T, Barnet JH, et al. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol 2013; 177:1006.
- Senthilvel E, Auckley D, Dasarathy J. Evaluation of sleep disorders in the primary care setting: history taking compared to questionnaires. J Clin Sleep Med 2011; 7:41.
- Namen AM, Wymer A, Case D, Haponik EF. Performance of sleep histories in an ambulatory medicine clinic: impact of simple chart reminders. Chest 1999; 116:1558.
- Redline S, Sotres-Alvarez D, Loredo J, et al. Sleep-disordered breathing in Hispanic/Latino individuals of diverse backgrounds. The Hispanic Community Health Study/Study of Latinos. Am J Respir Crit Care Med 2014; 189:335.
- Lee W, Nagubadi S, Kryger MH, Mokhlesi B. Epidemiology of Obstructive Sleep Apnea: a Population-based Perspective. Expert Rev Respir Med 2008; 2:349.
- Spurr K, Morrison DL, Graven MA, et al. Analysis of hospital discharge data to characterize obstructive sleep apnea and its management in adult patients hospitalized in Canada: 2006 to 2007. Can Respir J 2010; 17:213.
- Shear TC, Balachandran JS, Mokhlesi B, et al. Risk of sleep apnea in hospitalized older patients. J Clin Sleep Med 2014; 10:1061.
- Sharma S, Mather PJ, Efird JT, et al. Obstructive Sleep Apnea in Obese Hospitalized Patients: A Single Center Experience. J Clin Sleep Med 2015; 11:717.
- Khayat RN, Jarjoura D, Patt B, et al. In-hospital testing for sleep-disordered breathing in hospitalized patients with decompensated heart failure: report of prevalence and patient characteristics. J Card Fail 2009; 15:739.
- Khayat R, Jarjoura D, Porter K, et al. Sleep disordered breathing and post-discharge mortality in patients with acute heart failure. Eur Heart J 2015; 36:1463.
- Szymanski FM, Filipiak KJ, Platek AE, et al. Assessment of CHADS2 and CHA 2DS 2-VASc scores in obstructive sleep apnea patients with atrial fibrillation. Sleep Breath 2015; 19:531.
- Mehra R, Principe-Rodriguez K, Kirchner HL, Strohl KP. Sleep apnea in acute coronary syndrome: high prevalence but low impact on 6-month outcome. Sleep Med 2006; 7:521.
- Johnson KG, Johnson DC. Frequency of sleep apnea in stroke and TIA patients: a meta-analysis. J Clin Sleep Med 2010; 6:131.
- Correia LC, Souza AC, Garcia G, et al. Obstructive sleep apnea affects hospital outcomes of patients with non-ST-elevation acute coronary syndromes. Sleep 2012; 35:1241.
- Mokhlesi B, Hovda MD, Vekhter B, et al. Sleep-disordered breathing and postoperative outcomes after elective surgery: analysis of the nationwide inpatient sample. Chest 2013; 144:903.
- Hallowell PT, Stellato TA, Schuster M, et al. Potentially life-threatening sleep apnea is unrecognized without aggressive evaluation. Am J Surg 2007; 193:364.
- Goring K, Collop N. Sleep disordered breathing in hospitalized patients. J Clin Sleep Med 2008; 4:105.
- Al-Jawder S, Bahammam A. Utility of daytime polysomnography for in-patients with suspected sleep-disordered breathing. Neurol Neurochir Pol 2009; 43:140.
- Namen AM, Landry SH, Case LD, et al. Sleep histories are seldom documented on a general medical service. South Med J 2001; 94:874.
- Loo G, Hein T, Tai BC, et al. Screening of hospitalized patients at high risk of obstructive sleep apnea in general cardiology service. Int J Cardiol 2013; 164:368.
- Nader NZ, Steinel JA, Auckley DH. Newly identified obstructive sleep apnea in hospitalized patients: analysis of an evaluation and treatment strategy. J Clin Sleep Med 2006; 2:431.
- Cooksey JA, Balachandran JS. Portable Monitoring for the Diagnosis of OSA. Chest 2016; 149:1074.
- Kauta SR, Keenan BT, Goldberg L, Schwab RJ. Diagnosis and treatment of sleep disordered breathing in hospitalized cardiac patients: a reduction in 30-day hospital readmission rates. J Clin Sleep Med 2014; 10:1051.
- Chernyshev OY, McCarty DE, Moul DE, et al. A pilot study: portable out-of-center sleep testing as an early sleep apnea screening tool in acute ischemic stroke. Nat Sci Sleep 2015; 7:127.
- Farney RJ, Walker JM, Cloward TV, et al. Polysomnography in hospitalized patients using a wireless wide area network. J Clin Sleep Med 2006; 2:28.
- Wessendorf TE, Teschler H, Wang YM, et al. Sleep-disordered breathing among patients with first-ever stroke. J Neurol 2000; 247:41.
- Louis JM, Mogos MF, Salemi JL, et al. Obstructive sleep apnea and severe maternal-infant morbidity/mortality in the United States, 1998-2009. Sleep 2014; 37:843.
- Lindenauer PK, Stefan MS, Johnson KG, et al. Prevalence, treatment, and outcomes associated with OSA among patients hospitalized with pneumonia. Chest 2014; 145:1032.
- Ohmura T, Iwama Y, Kasai T, et al. Impact of predischarge nocturnal pulse oximetry (sleep-disordered breathing) on postdischarge clinical outcomes in hospitalized patients with left ventricular systolic dysfunction after acute decompensated heart failure. Am J Cardiol 2014; 113:697.
- Lee CH, Khoo SM, Chan MY, et al. Severe obstructive sleep apnea and outcomes following myocardial infarction. J Clin Sleep Med 2011; 7:616.
- Shah N, Redline S, Yaggi HK, et al. Obstructive sleep apnea and acute myocardial infarction severity: ischemic preconditioning? Sleep Breath 2013; 17:819.
- Sorscher AJ, Caruso EM. Frequency of provision of CPAP in the inpatient setting: an observational study : "CPAP provision in the inpatient setting". Sleep Breath 2012; 16:1147.
- de Miguel-Díez J, Carrasco-Garrido P, Jiménez-García R, et al. Obstructive sleep apnea among hospitalized patients in Spain, analysis of hospital discharge data 2008-2012. Sleep Breath 2015; 19:841.
- Guralnick AS, Pant M, Minhaj M, et al. CPAP adherence in patients with newly diagnosed obstructive sleep apnea prior to elective surgery. J Clin Sleep Med 2012; 8:501.
- Liao P, Luo Q, Elsaid H, et al. Perioperative auto-titrated continuous positive airway pressure treatment in surgical patients with obstructive sleep apnea: a randomized controlled trial. Anesthesiology 2013; 119:837.
- O'Gorman SM, Gay PC, Morgenthaler TI. Does autotitrating positive airway pressure therapy improve postoperative outcome in patients at risk for obstructive sleep apnea syndrome? A randomized controlled clinical trial. Chest 2013; 144:72.
- Khayat RN, Abraham WT, Patt B, et al. In-hospital treatment of obstructive sleep apnea during decompensation of heart failure. Chest 2009; 136:991.
- Mehta V, Vasu TS, Phillips B, Chung F. Obstructive sleep apnea and oxygen therapy: a systematic review of the literature and meta-analysis. J Clin Sleep Med 2013; 9:271.
- Hollier CA, Harmer AR, Maxwell LJ, et al. Moderate concentrations of supplemental oxygen worsen hypercapnia in obesity hypoventilation syndrome: a randomised crossover study. Thorax 2014; 69:346.
- Padeletti M, Green P, Mooney AM, et al. Sleep disordered breathing in patients with acutely decompensated heart failure. Sleep Med 2009; 10:353.
- Farney RJ, McDonald AM, Boyle KM, et al. Sleep disordered breathing in patients receiving therapy with buprenorphine/naloxone. Eur Respir J 2013; 42:394.
- Sériès F, Kimoff RJ, Morrison D, et al. Prospective evaluation of nocturnal oximetry for detection of sleep-related breathing disturbances in patients with chronic heart failure. Chest 2005; 127:1507.
- Collop NA, Anderson WM, Boehlecke B, et al. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med 2007; 3:737.
- Khayat R, Abraham W, Patt B, et al. Central sleep apnea is a predictor of cardiac readmission in hospitalized patients with systolic heart failure. J Card Fail 2012; 18:534.
- Van den Broecke S, Jobard O, Montalescot G, et al. Very early screening for sleep-disordered breathing in acute coronary syndrome in patients without acute heart failure. Sleep Med 2014; 15:1539.
- Carmona-Bernal C, Ruiz-García A, Villa-Gil M, et al. Quality of life in patients with congestive heart failure and central sleep apnea. Sleep Med 2008; 9:646.
- Lanfranchi PA, Braghiroli A, Bosimini E, et al. Prognostic value of nocturnal Cheyne-Stokes respiration in chronic heart failure. Circulation 1999; 99:1435.
- Javaheri S, Shukla R, Zeigler H, Wexler L. Central sleep apnea, right ventricular dysfunction, and low diastolic blood pressure are predictors of mortality in systolic heart failure. J Am Coll Cardiol 2007; 49:2028.
- Midgren B, Mared L, Franklin KA, et al. Cheyne-Stokes respiration is not related to quality of life or sleepiness in heart failure. Clin Respir J 2010; 4:30.
- Hagenah G, Zapf A, Schüttert JB. Cheyne-stokes respiration and prognosis in modern-treated congestive heart failure. Lung 2010; 188:309.
- Sano K, Watanabe E, Hayano J, et al. Central sleep apnoea and inflammation are independently associated with arrhythmia in patients with heart failure. Eur J Heart Fail 2013; 15:1003.
- Aurora RN, Chowdhuri S, Ramar K, et al. The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses. Sleep 2012; 35:17.
- Cowie MR, Woehrle H, Wegscheider K, et al. Adaptive Servo-Ventilation for Central Sleep Apnea in Systolic Heart Failure. N Engl J Med 2015; 373:1095.
- Aurora RN, Bista SR, Casey KR, et al. Updated Adaptive Servo-Ventilation Recommendations for the 2012 AASM Guideline: "The Treatment of Central Sleep Apnea Syndromes in Adults: Practice Parameters with an Evidence-Based Literature Review and Meta-Analyses". J Clin Sleep Med 2016; 12:757.
- Parra O, Arboix A, Bechich S, et al. Time course of sleep-related breathing disorders in first-ever stroke or transient ischemic attack. Am J Respir Crit Care Med 2000; 161:375.
- Enomoto M, Tsutsui T, Higashino S, et al. Sleep-related problems and use of hypnotics in inpatients of acute hospital wards. Gen Hosp Psychiatry 2010; 32:276.
- Isaia G, Corsinovi L, Bo M, et al. Insomnia among hospitalized elderly patients: prevalence, clinical characteristics and risk factors. Arch Gerontol Geriatr 2011; 52:133.
- Vico-Romero J, Cabré-Roure M, Monteis-Cahis R, et al. [Prevalence of sleep disorders and associated factors in inpatient]. Enferm Clin 2014; 24:276.
- Haynes PL, Parthasarathy S, Kersh B, Bootzin RR. Examination of insomnia and insomnia treatment in psychiatric inpatients. Int J Ment Health Nurs 2011; 20:130.
- Wang J, Greenberg H. Status cataplecticus precipitated by abrupt withdrawal of venlafaxine. J Clin Sleep Med 2013; 9:715.
- Gugger JJ, Wagner ML. Rapid eye movement sleep behavior disorder. Ann Pharmacother 2007; 41:1833.
- OBSTRUCTIVE SLEEP APNEA
- Evaluation and diagnosis in the inpatient setting
- - History and physical exam
- - Screening questionnaires
- - Overnight oximetry
- - Portable sleep apnea testing
- - Polysomnography
- Adverse inpatient outcomes
- - Patients with known OSA who use PAP at home
- - Patients with known OSA who use other therapies at home
- - Patients with newly diagnosed or previously untreated OSA
- - Review of concomitant medications
- - Role of nocturnal oxygen
- Post-discharge follow-up
- CENTRAL SLEEP APNEA
- High-risk groups
- Diagnosis in the inpatient setting
- Potential consequences
- - Patients with chronic insomnia
- - Patients with new insomnia in the hospital
- OTHER SLEEP DISORDERS
- SUMMARY AND RECOMMENDATIONS